Cannabis for Oncology Patients: A Clinical Review

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As the country continues its spirited conversation about expanding the legal use of cannabis, oncology practitioners have their eye on another issue: the role of marijuana in helping patients to manage the often debilitating symptoms that follow a cancer diagnosis.

Cannabis use goes back 3000 years to China, followed by a long and uneven history of ceremonial, recreational, and medicinal applications. Anecdotally, cannabis effectiveness is reported for a wide range of illnesses— including arthritis, chronic pain, fibromyalgia, glaucoma, multiple sclerosis, cancer, nausea, asthma, anxiety, depression, epilepsy, glaucoma, alcohol withdrawal, and infection1,2; however, seminal evidence is lacking to support cannabis as a reliable treatment.

More than half of the states in the United States have legalized some form of medical-use cannabis and more states are expected to join those ranks.3 This November, California is among several states to vote on cannabis legalization for recreational use; if the ballot measure passes there, momentum generated from that big state will build, likely prompting more states to consider legalization.

Sixteen states have enacted laws allowing the use of cannabis formulations that are low in the tetrahydrocannabinol (THC) associated with its psychological high, but high in cannabidiol (CBD), the compound believed to target various medical ailments and symptoms.4 More than 1700 strains of cannabis are currently available for purchase from authorized dispensaries. The delivery systems for administration are extensive, including smoking, vaping, edible foods and oils, tinctures, juices, teas, and salves.3,5

Political, economic, and medical interests want further clinical investigations into the pharmacology of cannabis and its efficacy in relieving various symptom and antitumor properties.4,6 In August, some restrictions on growing cannabis for research lifted, and now federally authorized researchers and drug companies may use cannabis grown in places other than its well-secured facility at the University of Mississippi.

Why the change? The Drug Enforcement Administration announced: “Under the new approach, should the state of scientific knowledge advance in the future such that a marijuanaderived drug is shown to be safe and effective for medical use, pharmaceutical firms will have a legal means of producing such drugs in the United States—independent of the [federal government] contracting process.”7

Cannabis Use for Oncology Patients
In the United States, cannabis is classified as a Schedule I drug due to what the government considers its high potential for abuse. Although efforts continue to change its classification, the FDA announced in August that the classification will not change, thus continuing to limit vigorous, targeted research that would expose cannabis’ potential as a treatment for many medical conditions.3,8

In daily practice, however, patients continue to ask their providers about using cannabis and finding ways to obtain it. And more and more, healthcare providers recommend cannabis as a promising strategy for oncology-related symptom management (Box: Provider Guidelines).

Provider Guidelines1,5,8

• Establish a treatment plan, based on patient history and physical.

• Consider if standard symptom management treatments are not working or have been exhausted.
• Prescribe to adults only (no prescribing to children or adolescents).
• Avoid prescribing if history of psychiatric disorders or known family history of psychiatric disorders.
• Address any interactions, eg, with dronabinol, since it is formulated with sesame oil and can pose a risk of anaphylaxis to those with a hypersensitivity to sesame seeds or nuts. Other contraindications to cannabinoid use include a history of seizures, and concurrent use of alcohol, sedatives, hypnotics, or other psychoactive agents. Patients taking cannabinoids should be advised not to drive.
• Individualize the dosing/titration plan, taking into account symptom relief and adverse effects.
• Recommend obtaining from a licensed dispensary operated under quality control guidelines and regulations.
• Regular follow-up and monitoring by providers, with accurate documentation.
• Base recommendations on updated, growing body of literature and evidencebased, rigorous clinical studies.

Nevertheless, providers may make cannabis recommendations with very little known about potential adverse effects, drug interactions, optimal dosing and administration, and overall strategies for tolerance and effectiveness.3